Opioids Are Not a First-Line Treatment for Chronic Pain, Pain Specialist Says

When someone living with HIV complains about chronic pain, take their word for it, but try non-opioid therapies and treat underlying psychiatric illnesses before prescribing oxycodone, Jessica S. Merlin, M.D., M.B.A., advised health care providers in a recent webinar. People living with HIV are more likely to suffer from such pain (30%-85% report chronic pain) than the general population (15% report that issue). This may be partly due to greater sensitivity to pain in those with detectable viral loads, Merlin explained.

Providers must understand the impact that this condition has on a patient's daily life, screen for mood disorders and note the patient's coping strategies before suggesting a therapy approach, Merlin advised in the Chronic Pain in HIV Infection: A Practical, Evidence-Based Approach webinar sponsored by the International Antiviral Society-USA on August 18, 2016. An effective technique Merlin has used in her chronic pain clinic is motivational interviewing, which is designed to stimulate people's own motivation for change, rather than simply telling them that they should change their behavior. She counseled providers to educate patients about ways to control pain without resorting to prescription medications, including mind-body techniques and short-term, over-the-counter drugs, such as acetaminophen. The latter, however, has problematic side effects when taken long-term, especially in combination with antiretrovirals, Merlin cautioned. Other approaches include physical therapy and exercise, as well as topical medications.

Providers should develop a team either within their office or within the community; it should include mental health professionals, methadone programs and social workers, among others. Such a team approach allows for better screening and treatment of depression, PTSD and other conditions that may co-occur with chronic pain. These problems need to be addressed first to remove the underlying cause of the pain, rather than treating only the symptoms.

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Opioids should not be considered first-line therapy for chronic pain, Merlin emphasized. Evidence of their benefit is limited, and no studies have evaluated their use for longer than one year. By contrast, evidence of their risks is mounting, with an estimated 10% of patients on such medications becoming addicted, as well as a risk of overdose, especially when co-prescribed with benzodiazepines. Providers should take universal precautions when prescribing opioids, rather than deciding who is or is not at risk of opioid use disorder. These precautions include having the patient sign an opioid treatment agreement, with provisions for using only one prescriber and one pharmacy and submitting to frequent urine drug testing. However, urine tests can result in false positives, especially when someone takes multiple medications, as is the case with those living with HIV, Merlin noted. A confirmatory assay, as well as a conversation with the patient, are therefore necessary before jumping to conclusions.

If all non-opioid attempts at managing the chronic pain have failed and oxycodone or a similar drug is prescribed, the lowest effective dose should be used. Patients should be re-assessed at least every three months, other therapies should be optimized, and the opioid dosage prescribed should be tapered off over time with the goal of eventually discontinuing it altogether. Merlin also advocated co-prescribing naloxone for high-risk patients, if they can bring in someone who lives with them and can administer the antidote in case of opioid overdose. However, local laws differ as to whether this approach is permitted. Laws on marijuana use also differ among states, but where legal the substance may be useful in treating chronic pain. Evidence shows that people who are prescribed medical marijuana use opioids less, reducing the risks associated with opioids.

Comment by: Concerned as Well
(San Francisco, CA)
Wed., Oct. 19, 2016 at 11:48 pm UTC
I agree with Concerned -- and am in a similar boat. The few that abuse opioids have made it impossible for me, a person living with sever pain every day of my life, to get the pain killing medications that I need to live a normal life. I have been unemployed for six years because I find it impossible to move normally without being in severe pain, yet my doctor's (or the policy of the facility where I get my HIV treatment) policy prevents him/her from writing a Rx for opioids. I was referred to a local hospital's pain clinic, only to find out that it was a non-opioid pain clinic and after consultation with the doctors there, concluded that there was nothing that they could do for me. I am now in negotiations with yet another doctor for a possible opioid Rx, but because she doesn't know me, will require, urine drug screens, narcotic drug contract, appointments every three months, etc. IF she decides eventually even to write a Rx for opioids. We are trying all the other options first (which I have already tried before with other doctors), but she insists. Initially, my first pain management doctor prescribed so little of an opioid that I took ibuprofen additionally in such amounts that it damaged my kidneys to the point that I now suffer from chronic kidney disease and am unable to take any NSAIDs. These are just a few examples of how doctors, trying to be good doctors and spare the use of opioids, put the patient at risk. Please keep us in mind when you write such articles that say to use opioids as a last resort and at the lowest dose possible. For some patients opioids are what they need -- and not at the lowest dose possible.

Comment by: Concerned
(Oklahoma)
Wed., Oct. 12, 2016 at 2:02 pm UTC
Having suffered from chronic pain for more than 15 years, these sorts of efforts are a great source of concern. Granted, 10% of users may become addicted, but as a result, prescription pain killers have become almost impossible to get. They are the only thing that has worked for me. I tire of unnecessarily seeing my doctor every three months - it is inconvenient and expensive. I tire of getting drug tests - also inconvenient and expensive. After all this time without becoming addicted, I am still treated as a suspect. There is no trust between my provider and me. That is not a good relationship to have when trust is a cornerstone of quality HIV care. I run out of a medication and must go without for weeks before I can get in to see my doctor for the next renewal. Even between visits, the delays can be unbearable. Without my medication. I cannot sleep due to pain. During the day, I can barely function because getting around is so painful. There is a treatment that works for me, but because a small minority of users have become addicted, it is hardly accessible. Well, there are side effects of most drugs, but access to them has not been denied due to those side effects. Why should pain killers be any different? I don't even use opioids, but the medications I do use are considered at risk of being abused. Therefore, I am required to follow unreasonable requirements so I can live my life with less pain. Please, let's be more realistic and admit that pain killers are important for some. Rather than having these folks jump through hoops for treatment, let's show a bit more respect for their self-assessments and needs. It is okay to use caution when subscribing risky meds, but don't go overboard. Why use HIV treatment to live a long life when every day of that life is occupied with chronic pain?

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